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250 Fractionated radiation therapy for malignant brain tumors


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Youmans Neurological Surgery

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250 Fractionated radiation therapy for malignant brain tumors

  1. 1. 250 Fractionated Radiation Therapy for Malignant Brain Tumors Youmans Neurological surgery 13/09/2559 George M. Cannon Minesh P. Mehta
  2. 2. Outline • Brain metastasis • Malignant glioma • Anaplastic Astrocytoma • Anaplastic Oligodendroglioma • Primary CNS lymphoma • Malignant meningeal tumor • Primitive Neuroectodermal Tumors • Germ Cell Neoplasms
  3. 3. Brain metastasis • Most common : lung, breast, melanoma • Less common : primary tumors of the gastrointestinal tract and genitourinary system, lymphomas, sarcomas, and prostate cancer • Median survival time of untreated patients with brain metastases is approximately 1 month
  4. 4. Fractionation Trials
  5. 5. Prognostic Factor analysis Class I : KPS ≥ 70, Age ≤ 60, control primary and absence of extracranial metastasis Class III : KPS < 70
  6. 6. Prognostic Factor analysis • 0-1 median survival time 2.6 months • 1.5-2.5 median survival time 3.8 months • 3 median survival time 6.9 months • 3.5-4.0 median survival time 11 months
  7. 7. Role of Adjuvant Whole-Brain Radiotherapy no significant difference in overall survival between the two groups, even though the study was not powered to detect a survival difference
  8. 8. Side Effects of Whole-Brain Radiotherapy • Acute side effect • fatigue, hair loss, particularly along the midline and vertex, erythema, and otitis • Months to years side effect • Impairment of neurocognitive function • Survived longer than 1 yrs • Neurotoxicity with progressive dementia, ataxia and urinary incontinence • Neurocognitive function factor • presence of brain metastases, neurosurgical interventions, chemotherapy, and other neurotoxic therapies such as steroids and anticonvulsants
  9. 9. Reirradiation of Brain metastasis • Aggressive, primary treatment interventions to provide durable local control is obviously preferable to being backed into this unfortunate situation of recurrent intracranial disease with limited treatment options.
  10. 10. Summary • 30 Gy in 10 fractions given over 2 wks
  11. 11. Glioblastoma multiforme • Diffusely infiltrative the brain parenchyma • Can’t complete microscopic surgical excision • Grade IV
  12. 12. Utility of radiation therapy Compare mithramycin vs surgical alone ; no differ in mithramycin use Post-operative carmustine(BCNU) ; WBRT improve survival Post-operative semustine(MeCCNU) ; MeCCNU infeior GBM surgical resection with or without RT ; improve in WBRT
  13. 13. Radiation Target Volume • Planned target volume 1 (PTV1) • the contrast-enhancing lesion, • resection cavity • surrounding edema if present (best seen on T2-weighted images) • followed by a 2.0-cm expansion • Planned target volume 2 (PTV2) • After 46 Gy of radiation • the contrast-enhancing lesion with a 2.5-cm expansion
  14. 14. Recurrence Patterns • The recurrent tumor that surpassed the outside surface of the PTV was still predominantly centered within the tumor bed • Central or in-field
  15. 15. Dose Escalation
  16. 16. Prognostic Factor Analysis
  17. 17. Prognostic Factor Analysis Methylguanine-deoxyribonucleic acid methyltransferase (MGMT) methylation has also proved to be a powerful predictor of survival in patients receiving RT and TMZ
  18. 18. Anaplastic Astrocytoma • Grade III astrocytoma • Median survival in the 2- to 3-year range • Partial brain fields • GTV(Gross total volume) : hypodense edema or T2 abnormality, contrast-enhancing volume • CTV(Clinical target volume): 2- to 3-cm margin of tissue surrounding the GTV. • The initial volume is typically treated to 46 Gy and the boost volume to 60 Gy • Median survival decreased with more aggressive therapy • RT + CMT did not achieve better compare with RT alone
  19. 19. Anaplastic Oligodendroglioma • Chemotherapy potentially improves PFS, but the effect on survival is not statistically obvious • Patients with 1p and 19q deletions had significantly better outcomes • MGMT promoter methylation : TMZ
  20. 20. Primary central nervous system lymphoma • lymphoma confined to the CNS • Dissemination through the craniospinal axis • Radiosensitive tumor • 40-50 Gy total • Chemotherapy • Younger than 60 yrs,better prognois
  21. 21. Malignant Meningeal Tumors • Hemangiopericytoma • Slow but progressive radiographic response to ionizing radiation • Significant metastasis : liver, lung, bone and soft tissue • Effetiveness is dubious [Greenberg] • Malignant meningioma • Aggressive surgical resection followed by postoperative high-dose RT • 5 Yr survival less thans 20% • GTV : expan 1.5-2 cm. • 55-60 Gy [Greenberg]
  22. 22. Primitive Neuroectodermal Tumors • sheets of small round blue cells with scant cytoplasm • supratentorial PNET, pineoblastoma, medulloblastoma, and ependymoblastoma • “standard risk” or “high risk” • age, Chang M stage, location, and extent of resection • Standard-risk patients : • Chang M0 stage disease (no evidence of microscopic or macroscopic dissemination along the craniospinal axis) • posterior fossa origin • age older than 3 years • less than 1.5-cm2 tumor residual after surgery
  23. 23. Primitive Neuroectodermal Tumors • Craniospinal RT at recommended doses of 36 Gy to the craniospinal axis and a posterior fossa boost to 54 Gy • 35-40 Gy to whole craniospinal axis + 10-15 Gy boost to tumor bed(usually posterior fossa) [Greenberg] • Combination chemotherapy given with craniospinal RT continues to be pursued
  24. 24. Germ Cell Neoplasms • CNS germinomas have been managed with craniospinal RT • Nongerminomatous germ cell tumors of the CNS, survival is significantly poorer, and both surgical resection and chemotherapy are the primary modalities of treatment
  25. 25. Complication • Acute : occur during and immediately after completion of a course of external beam • Acute skin reaction : dry desquamation, erythema • Temporary alopecia • Fatigue • Flash of light • Serous otitis media • Uncommon : Nausea, increase intracranial hypertension
  26. 26. Complication • Subacute : several week of month after complete RT • Lethargy and somnolence • Children : acute somnolence syndrome • N/V, ataxia, dysphagia, cerebellar ataxia • Keratoconjunctivitis • Radiation necrosis : PET or MRS
  27. 27. Complication • Late complication : several month to years • Unclear because short-term survivor • Impairment of intellectual function : memory and mathmetical ability • Dementia, ataxia, confusion